Gender

After a long process of clarifying my transition goals, I was finally able to create a prescription plan to help achieve a more androgynous appearance without complete masculinization. I initially felt confident about my plans for hormone therapy. However, in the weeks leading up to my appointment with a new family doctor who could provide these prescriptions, I began to feel more uncertain about starting testosterone – I wondered whether recent improvements in body image could be sustained without drugs, and I was concerned about potential side effects even on low doses of T and finasteride.

I also felt anxious that the doctor may not understand or support my atypical transition goals. In my experience, people’s ignorance of gender dysphoria can often lead to misunderstanding or hostility and judgment. But people’s knowledge of gender dysphoria, from personal or professional experience, can also create frustrating barriers to understanding and acceptance. Other trans people, whose experience aligns more closely with typical trans narratives, often respond defensively or dismissively to my uncertainty about gender identity and my ambivalence about pursuing medical transition options. Medical professionals, whose work with other trans patients informs their perspective on gender dysphoria, often convey wildly inaccurate assumptions about my experience. These assumptions usually become evident in their well-intentioned attempts to demonstrate knowledge and acceptance. But these assumptions do not make me feel accepted; they make me feel invisible.

When I arrived for my appointment, it was immediately apparent that the doctor had made some problematic assumptions. He assumed that I wanted to achieve maximum masculinization as quickly as possible – before I had even mentioned my transition goals, he delivered several warnings about the risks of taking too much testosterone and several reassurances that I should start seeing physical changes very soon on standard doses. He assumed that he would have to educate me about hormone therapy – he interrupted me constantly to deliver very basic information that I already knew. And he assumed that I would trust his opinion – he emphasized the fact that he had worked with “lots” of trans patients to support his recommendations, with little reference to specific clinical experiences or published literature.

His inaccurate assumptions and his tendency to interrupt meant that it took much longer than necessary for me to explain my situation. Eventually, in an abbreviated and fragmented fashion, I was able to describe my transition goals. He said that my experience is “atypical” and admitted that he doesn’t have many patients who want to transition slowly and partially. But by the end of the appointment, he seemed to understand my perspective and he was supportive of my desire to proceed cautiously (or potentially not even start T right away). He gave me the prescriptions I requested: 1.25g/day Androgel and 1.25mg/day finasteride.

I mentioned my concern about T potentially causing mood fluctuations (less likely with lower doses and transdermal formulations). He cheerfully reassured me that mood issues aren’t a problem in patients on much higher doses of injectable T, so he would expect no changes in mood on the dose of Androgel that I requested, although I might experience slightly increased energy on T. While that information was somewhat comforting, I wondered if there may be some bias in his clinical experience which could lead to underestimation of the effects of T on mood. I have previously described how trans people may tailor the information they share with doctors who control access to transition options. If someone is desperate to continue hormones but experiences negative mood side effects, they might be motivated to withhold that information from the doctor to avoid being told to decrease the dose or discontinue hormones.

I also mentioned my fear that T could cause increased appetite and significant weight gain. Even if the weight gain was related to a desirable increase in muscle mass, these sides effects would be very difficult for me to cope with due to a long history of disordered eating. He again cheerfully reassured me that weight gain is usually minimal even on higher doses of T, typically characterized by a slight increase in muscle mass with concurrent decrease in body fat so that the number on the scale may remain stable or increase by only a few pounds. He said that people who do experience significant weight gain after starting T are generally gaining weight for reasons other than the hormones, so if I maintained the same exercise and diet routine after staring T then I shouldn’t expect much change in weight and appetite. Changes in body weight can be assessed more objectively than changes in mood, so it seems that clinicians’ observations of weight changes are less likely to be biased by selective disclosure from patients.

Finally, I asked him whether long-term use of low-dose T would eventually lead to complete masculinization (just on a much slower timeline than higher doses) or whether it would allow partial masculinization to a stable endpoint that could be sustained and non-progressive over time. The doctor was very confident in saying that it would be the latter (partial non-progressive masculinization). But I have found no published evidence to support either conclusion, and the doctor admitted that he has “very few” patients who elect to start on a low dose of T (let alone maintain a low dose of T indefinitely) so it seems that his clinical experience with respect to this question would be relatively limited. [Several weeks later, I discussed the same question with a psychiatrist who specializes in working with transgender people. The psychiatrist said that the endocrinologists he’s worked with believe long-term low-dose T would eventually (over decades) lead to complete masculinization, which directly contradicts the family doctor’s response to my question. It seems there are no definitive answers available].

So I left the appointment with two prescriptions and more questions than answers. My instinctive desire for certainty grappled with my relentless tendency for skepticism. I was grateful that I had been given the prescriptions I requested, grateful that I had the freedom to move forward with hormone therapy whenever I wanted – a freedom that many trans people do not have. But as I reviewed the prescriptions and the lengthy consent form outlining all potential risks and side effects, I still found myself questioning more intensely whether this drugs are truly right for me, or whether I could find a way to be comfortable in this XX body without hormonal or surgical intervention.

“We make all sorts of assumptions because we don’t have the courage to ask questions.” – Miguel Ruiz (The Four Agreements: A Practical Guide to Personal Freedom, 2001)

————~ Part 1 in the Testosterone Series ~Part 2: Assumptions and Questions
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When I initially reviewed the literature on hormone therapy for FTMs over a year ago, I hoped to find quick and easy answers about testosterone. At that time, I had a simplistic and optimistic belief that gender dysphoria was the main issue contributing to depression and other life issues, so I felt a desperate urgency to start medical transition as soon as possible. But because I was still so unsure about my own transition goals, my research felt disorganized and overwhelming and served only to magnify the intensity of my uncertainty.

But after resolving my chronic confusion with the concept of “gender identity,” deconstructing many of my own illusions about my appearance, creating a more concrete mental image of my “ideal” body, and gaining a greater measure of acceptance of my current body, I was finally able to consider hormone therapy with more clarity. As I described previously, my “ideal” body does not align with that of typical cisgender men. Rather, my “ideal” body would have somewhat more masculine facial features and a slightly more masculine silhouette than my current female frame (broader shoulders, more upper body muscle mass, wider waist, narrower hips), but would otherwise be more androgynous than masculine. So I revisited my old research with this new lens, and I was able to create what seemed to be an optimal hormone therapy plan to accomplish my desired physical changes.

It is beyond the scope of this post to summarize all of the published information regarding hormone therapy for FTMs. I present here my own tentative prescription plan with reference to information most relevant to my situation. I hope this may be valuable to others seeking to achieve slight and gradual physical masculinization outside standard FTM hormone therapy protocols. Recent publications have acknowledged increasing diversity in transition goals among gender dysphoric individuals. (Fabris 2006)

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Testosterone (T): 1-2g/day transdermal

Transdermal T is available as a gel or as a patch. I planned to consult with my prescribing physician about the availability and cost of those options in my area. Injectable (intramuscular) T formulations are most commonly preferred and prescribed for FTMs. (Simpson 2006, Meriggiola 2015) However, compared to the various injectable T formulations, transdermal T has several advantages with respect to my own transition goals.

First, transdermal formulations are associated with more stable serum T concentrations over time that mimic the physiologic secretion of T in cisgender men. (Simpson 2006, Meriggiola 2015) Intramuscular injections of T every 1-4 weeks cause supraphysiologic serum concentrations in the first few days after the injection, followed by a rapid decrease in T concentration. (Meriggiola 2015) Some studies report changes in energy and more pronounced mood swings associated with these rapid fluctuations in T concentration. (Simpson 2006, Meriggiola 2015) Mood changes include more frequent irritability, frustration/anger, and aggression as well as decreased positive and negative affect intensity. (Slabbekorn 2001, Simpson 2006) Maintaining a more consistent T concentration may help reduce mood changes, which is an important consideration for me given repeated episodes of severe depression.

Second, transdermal T may be associated with more gradual physical changes compared to injectable T. (Simpson 2006) “Transdermal formulations are recommended if slower progress is desired or for ongoing maintenance after desired virilization has been accomplished.” (TransHealth UCSF 2016). However, at comparable doses, transdermal and injectable T are associated with a similar overall degree of physical masculinization despite the slower progression of changes occurring with transdermal preparations. (Merrigiola 2015) Many FTMs hope to achieve pronounced physical masculinization as quickly as possible, but given my more conservative transition goals, I would prefer more gradual changes so that I have a longer period of time to evaluate whether the physical changes are truly desirable.

Third, transdermal T eliminates the requirement of giving myself intramuscular injections. I have an embarrassingly low pain tolerance, so I will admit that the prospect of injecting several millilitres of viscous oil into myself every few weeks is very unappealing.

Disadvantages of transdermal T in my situation include increased cost (my current health coverage is limited and does not include the off-label prescription of T for gender transition) as well as possibility for delayed cessation of menstruation (menstruation has always been a core source of body dysphoria for me and is one of the primary motivations to seek hormone therapy). (Simpson 2006) However, other studies have found that transdermal T induces amenorrhea on a similar timeline as injectable T. (Pelusi 2014)

The recommended maintenance dose range of transdermal T for FTMs who want to achieve considerable masculinization as quickly as possible is 2.5-10g per day. (Simpson 2006, Fabris 2015, Meriggiola 2015) A dose of 1-2g per day would likely allow even more gradual progress. Lower starting doses, such as 2.5g per day, are also recommended if there are concurrent psychiatric problems.(Simpson 2006)

Finasteride: 1mg/day oral

I previously discussed my desire to avoid hair loss by using finasteride concurrently with T. In addition to reducing male-pattern baldness in FTMs, finasteride can also be associated with slowed or decreased facial and body hair growth and slowed or decreased clitoromegaly. (TransHealth UCSF 2016) These effects are usually listed as disadvantages in articles about hormone therapy in FTMs. However, given my desire for only slight physical masculinization, these side effects are actually advantages because they align closely with my transition goals. The recommended dose of oral finasteride is 1mg/day. (Mella 2010)

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In the process of more seriously considering hormone therapy and trying to develop my own prescription plan, I returned to an important question from a previous post:

In an XX person, would long-term administration of low dose T ultimately lead to complete physical masculinization, but at a much slower pace than higher doses of T? Or would long-term administration of low dose T lead to partial masculinization that would be sustainable and non-progressive past a certain point? I am hoping very strongly for the latter. I have started looked for published data to answer this question, but so far I have only found articles describing the effects of long-term administration of high dose T in FTMs or describing the effects of short-term administration of low dose T in women (including the effects of exogenous T administered to treat various medical conditions as well as the effects of endogenous T in women with polycystic ovarian syndrome). However, there seem to be no studies describing the effects of long-term administration of low dose T in female-bodied people without concurrent medical issues.

I want to achieve a sustainable, non-progressive, partial physical masculinization. But I am not sure to what extent this goal is possible, even with conservative use of low dose hormones.

The scientific literature regarding long-term outcomes of low dose T administration in healthy XX individuals is almost non-existent. The literature regarding the extent and timeline of physical and psychological changes on low dose T is also extremely limited. Virtually everything currently published in scientific journals about T-induced changes in FTMs describes study participants on doses of T that are 2-10 times higher than the doses I’m considering. (Fabris 2015, Meriggiola 2015, Slabbekorn 2001, Pelusi 2014) There are some anecdotal reports of the effects of low dose T on blogs and YouTube videos by transmasculine people, but their comments tend to be sporadic, unstructured, and inconsistent.

This scarcity of published information about the short-term and long-term effects of low dose T contributes to my chronic difficulty imagining a future version of myself. For those of us with atypical transition goals, most of the existing medical knowledge and established hormone protocols are simply not applicable. This creates a painful sense of isolation and confusion, as though I’m peering out at the rest of the world from behind a foggy looking-glass.

“It’s dreadfully confusing!” – Alice (Lewis Carroll, Through the Looking-Glass and What Alice Found There, 1871)

The most commonly viewed post on this blog is Part 1 of this series: GIDYQ-AA Personal Reflection. The popularity of this post likely reflects considerable curiosity regarding the diagnostic process for gender dysphoria. Part 1 only listed a handful of questions from the questionnaire in the context of my personal reflection. It is nearly impossible to find a complete version of the GIDYQ-AA online without access to scientific journals through academic servers, so I thought it might be helpful for readers to dedicate a post to the full text of the GIDYQ-AA.

Below, I have recorded the Female Assigned at Birth and Male Assigned at Birth versions of the GIDYQ-AA in their entirety. I created my own GIDYQ-AA documents formatted for printing, including a table to record responses to questions and a section for scoring; these documents are available for download. I also have a section describing the scoring process in detail. Finally, abstracts from the study describing initial development of the GIDYA-AA (Deogracias 2007) and from a study providing further evidence to support the validity of the GIDYQ-AA (Singh 2010) are also included.

GIDYQ-AA (Female Assigned at Birth) Full TextResponse options are “always,” “often,” “sometimes,” “rarely,” or “never.” Items 1, 13, and 27 were reversed scored. For adolescents < 18 years of age, the word woman was changed to girl. Items 1-2, 5-10, 16, and 24-27 were considered to be subjective indicators of gender identity/gender dysphoria. Items 3-4, 11, 13-15, and 17-19 were considered social indicators. Items 20-22 were considered somatic indicators. Items 12 and 23 were considered sociolegal indicators.

01. In the past 12 months, have you felt satisfied being a woman?
02. In the past 12 months, have you felt uncertain about your gender, that is, feeling somewhere in between a woman and a man?
03. In the past 12 months, have you felt pressured by others to be a woman, although you don’t really feel like one?
04. In the past 12 months, have you felt, unlike most women, that you have to work at being a woman?
05. In the past 12 months, have you felt that you were not a real woman?
6. In the past 12 months, have you felt, given who you really are (e.g., what you like to do, how you act with other people), that it would be better for you to live as a man rather than as a woman?
07. In the past 12 months, have you had dreams? If NO, skip to Question 8. If YES, Have you been in your dreams? If NO, skip to Question 8. If YES, In the past 12 months, have you had dreams in which you were a man?
08. In the past 12 months, have you felt unhappy about being a woman?
09. In the past 12 months, have you felt uncertain about yourself, at times feeling more like a man and at times feeling more like a woman?
10. In the past 12 months, have you felt more like a man than like a woman?
11. In the past 12 months, have you felt that you did not have anything in common with either men or women?
12. In the past 12 months, have you been bothered by seeing yourself identified as female or having to check the box “F” for female on official forms (e.g., employment applications, driver’s license, passport)?
13. In the past 12 months, have you felt comfortable when using women’s restrooms in public places?
14. In the past 12 months, have strangers treated you as a man?
15. In the past 12 months, at home, have people you know, such as friends or relatives, treated you as a man?
16. In the past 12 months, have you had the wish or desire to be a man?
17. In the past 12 months, at home, have you dressed and acted as a man?
18. In the past 12 months, at parties or at other social gatherings, have you presented yourself as a man?
19. In the past 12 months, at work or at school, have you presented yourself as a man?
20. In the past 12 months, have you disliked your body because it is female (e.g., having breasts or having a vagina)?
21. In the past 12 months, have you wished to have hormone treatment to change your body into a man’s?
22. In the past 12 months, have you wished to have an operation to change your body into a man’s (e.g., to have your breasts removed or to have a penis made)?
23. In the past 12 months, have you made an effort to change your legal sex (e.g., on a driver’s licence or credit card)?
24. In the past 12 months, have you thought of yourself as a “hermaphrodite” or an “intersex” rather than as a man or woman?
25. In the past 12 months, have you thought of yourself as a “transgendered person”?
26. In the past 12 months, have you thought of yourself as a man?
27. In the past 12 months, have you thought of yourself as a woman?

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GIDYQ-AA (Male Assigned at Birth) Full TextResponse options are “always,” “often,” “sometimes,” “rarely,” or “never.” Items 1, 13, and 27 were reversed scored. For adolescents < 18 years of age, the word man was changed to boy. Items 1-2, 5-10, 16, and 24-27 were considered to be subjective indicators of gender identity/gender dysphoria. Items 3-4, 11, 13-15, and 17-19 were considered social indicators. Items 20-22 were considered somatic indicators. Items 12 and 23 were considered sociolegal indicators.

01. In the past 12 months, have you felt satisfied being a man?
02. In the past 12 months, have you felt uncertain about your gender, that is, feeling somewhere in between a man and a woman?
03. In the past 12 months, have you felt pressured by others to be a man, although you don’t really feel like one?
04. In the past 12 months, have you felt, unlike most men, that you have to work at being a man?
05. In the past 12 months, have you felt that you were not a real man?
06. In the past 12 months, have you felt, given who you really are (e.g., what you like to do, how you act with other people), that it would be better for you to live as a woman rather than as a man?
07. In the past 12 months, have you had dreams? If NO, skip to Question 8. If YES, Have you been in your dreams? If NO, skip to Question 8. If YES, In the past 12 months, have you had dreams in which you were a woman?
08. In the past 12 months, have you felt unhappy about being a man?
09. In the past 12 months, have you felt uncertain about yourself, at times feeling more like a woman and at times feeling more like a man?
10. In the past 12 months, have you felt more like a woman than like a man?
11. In the past 12 months, have you felt that you did not have anything in common with either women or men?
12. In the past 12 months, have you been bothered by seeing yourself identified as male or having to check the box “M” for male on official forms (e.g., employment applications, driver’s license, passport)?
13. In the past 12 months, have you felt comfortable when using men’s restrooms in public places?
14. In the past 12 months, have strangers treated you as a woman?
15. In the past 12 months, at home, have people you know, such as friends or relatives, treated you as a woman?
16. In the past 12 months, have you had the wish or desire to be a woman?
17. In the past 12 months, at home, have you dressed and acted as a woman?
18. In the past 12 months, at parties or at other social gatherings, have you presented yourself as a woman?
19. In the past 12 months, at work or at school, have you presented yourself as a woman?
20. In the past 12 months, have you disliked your body because it is male (e.g., having a penis or having hair on your chest, arms, and legs)?
21. In the past 12 months, have you wished to have hormone treatment to change your body into a woman’s?
22. In the past 12 months, have you wished to have an operation to change your body into a woman’s (e.g., to have your penis removed or to have a vagina made)?
23. In the past 12 months, have you made an effort to change your legal sex (e.g., on a driver’s licence or credit card)?
24. In the past 12 months, have you thought of yourself as a “hermaphrodite” or an “intersex” rather than as a man or woman?
25. In the past 12 months, have you thought of yourself as a “transgendered person”?
26. In the past 12 months, have you thought of yourself as a woman
27. In the past 12 months, have you thought of yourself as a man?

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GIDYQ-AA Scoring
The table at the bottom of the photo above shows how the questionnaire is scored. The scoring process is the same for the female-assigned-at-birth and the male-assigned-at-birth versions. I have summarized the scoring process in more detail below.

Participant fills out the questionnaire, indicating how often each question applies to them (“always,” “often,” “sometimes,” “rarely,” or “never”).

The number of X’s in each category (“always,” “often,” “sometimes,” “rarely,” and “never”) are added up. Items 1, 13, and 27 are reversed scored, which means that for those questions, an “always” response would actually be counted as “never” and an “often” response would actually be counted as “rarely.”

The total number of responses in each category (including reverse scored items) are then multiplied by weighting factors: the number of “always” responses is multiplied by 1, the number of “often” responses is multiplied by 2, the number of “sometimes” responses is multiplied by 3, the number of “rarely” responses is multiplied by 4, and the number of “never” responses is multiplied by 5.

The multiplied totals for each category are then added together to give the Raw Score.

The Raw Score is then divided by 27 to give the Scaled Score. (Note: if participants left any items blank, the Raw Score is divided by the total number of items completed. For example, if a participant did not respond to 2 of the items on the questionnaire, the Raw Score would be divided by 25 instead of by 27 to give the Scaled Score).

Based on published studies evaluating the GIDYQ-AA, a Scaled Score less than 3.0 is strongly suggestive of gender dysphoria, while a Scaled Score greater than 3.0 is more likely to reflect the absence of gender dysphoria. However, no single questionnaire or scoring system can perfectly capture all of the variation in gender identity and personal goals (and I have previously discussed many of the problems that I think may interfere with the utility of the questionnaire), so scores on the GIDYQ-AA are not necessarily definitive and should not replace each individual’s sense of their own identity.

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“The present study reports on the construction of a dimensional measure of gender identity (gender dysphoria) for adolescents and adults. The 27-item gender identity/gender dysphoria questionnaire for adolescents and adults (GIDYQ-AA) was administered to 389 university students (heterosexual and nonheterosexual) and 73 clinic-referred patients with gender identity disorder. Principal axis factor analysis indicated that a one-factor solution, account ing for 61.3% of the total variance, best fits the data. Factor loadings were all >.30 (median, .82; range, .34-96). A mean total score (Cronbach’s alpha, .97) was computed, which showed strong evidence for discriminant validity in that the gender identity patients had significantly more gender dysphoria than both the heterosexual and nonheterosexual university students. Using a cut-point of 3.00, we found the sensitivity was 90.4% for the gender identity patients and specificity was 99.7% for the controls. The utility of the GIDYQ-AA is discussed.” (abstract, Deogracias 2007)

“This study aimed to provide further validity evidence for the dimensional measurement of gender identity and gender dysphoria in both adolescents and adults. Adolescents and adults with gender identity disorder (GID) were compared to clinical control (CC) adolescents and adults on the Gender Identity=Gender Dysphoria Questionnaire for Adolescents and Adults (GIDYQ–AA), a 27-item scale originally developed by Deogracias et al. (2007). In Study 1, adolescents with GID (n1⁄444) were compared to CC adolescents (n1⁄498); and in Study 2, adults with GID (n1⁄441) were compared to CC adults (n1⁄494). In both studies, clients with GID self-reported significantly more gender dysphoria than did the CCs, with excellent sensitivity and specificity rates. In both studies, degree of self-reported gender dysphoria was significantly correlated with recall of cross-gender behavior in childhood—a test of convergent validity. The research and clinical utility of the GIDYQ–AA is discussed, including directions for further research in distinct clinical populations.” (abstract, Singh 2010)

Before I ever start a drawing, I spend a lot of time analyzing the face in the reference photo, observing the technical aspects of facial proportions and composition and contrast, and figuring out how to capture the emotion in their expression. It’s an intellectual and artistic analysis done from a detached, non-judgmental, keenly observant, and empathetic perspective. This process has completely changed the way I see my own face in the mirror. Now I see my face with so much more interest – what’s unique about her face? how would I capture her expression there? – now I see my face with so much more compassion.

Drawing my self portrait (titled #1 because I think there will be more!) was very strange at first, like an out-of-body experience, similar to my mirror experiments but more prolonged and more precise. I deliberately drew all the facial imperfections that have long been a source of self-consciousness for me: acne scars on my left cheek, the vein that so prominently traverses my left temple, right iris heterochromia.

After I finished the sketch, I realized that I actually like my eyes – they are very big, very expressive, and asymmetrically colourful. I also like my collarbones and the upper pectoral definition on my chest, the hard-earned result of thousands of pushups. And I’ve always loved my short, messy hair.

I never thought I would be capable of drawing my own face. My self portrait took six hours to complete… six hours staring at my face, after six years of showering in the dark and avoiding mirrors with pathological self-loathing.

Reference: photo of myself taken July 16, 2016 on the stairs at a city train station. I chose that photo because the lighting provided good contrast and the cautious, wary facial expression is characteristic of my chronic skepticism.

Comments: I sign most of my drawings as TM. But I have as many names as I do clothes, so when I started drawing again, I was initially unsure what my signature should be. Most commonly I go by Thomas or by my given name (which starts with J), so I decided to sign with a provisional TM. I can turn the T into a capital J with a single curved stroke of the pen if I want. I signed this self portrait with JM because my given name and the face I drew have been mine my whole life. Thomas is a newer addition.

Irene Adler: Do you know the big problem with a disguise, Mr. Holmes? However hard you try, it’s always a self-portrait.Sherlock Holmes: You think I’m a vicar with a bleeding face?Irene Adler: No, I think you’re damaged, delusional and believe in a higher power. In your case, it’s yourself. And somebody loves you. – BBC Sherlock (S02, E01 – A Scandal in Belgravia)

In my first mirror experiment, I was wearing a fitted tank top and baggy sweatpants, sitting cross-legged on a stainless steel shelf across from the mirror in my hospital bathroom. So my reflection focused on my face and upper body. I had intentionally chosen baggy pants and a cross-legged position to conceal my hips and thighs, which have long been a prominent source of body dysphoria. Perhaps that was cheating, a bit – after all, I had challenged myself to evaluate my mirror image as objectively as possible. Despite a little cheating, that mirror experiment generated so many important insights, allowing me to create a more positive and more realistic current body image as well as a more concrete idea of what my ideal body looks like to help guide transition choices.

Since then, I have repeated the mirror experiment countless times, for shorter periods. I pushed myself to continue stripping away the cognitive and physical illusions I have used for so long to detach myself from every aspect of my body. I pushed myself to look at my reflection wearing tighter pants, like jeans and workout capris. I pushed myself to change my position, sometimes sitting with my legs stretched out or dangling off the shelf, sometimes standing or leaning against the wall, legs apart and legs crossed. And I pushed myself to engage with my own image, not just in bathroom mirrors, but also in all the other reflective surfaces that bounce our selves back to us as we move through this fragmented world: the darkened window of a gift shop after closing, the smudged glass of a framed grad photo, the shiny plastic of a gas-station trashcan, the metallic blade of a new kitchen knife, the sleeping screen of an open laptop, the mysterious blackness of a stranger’s sunglasses or the familiar blue of a close friend’s eyes.

So my reflection has become a dynamic and ever-present companion. Reflection on reflection remains an intriguing process. And as I’ve expanded my mental library of my own reflected images, I have added incremental insights and deeper awareness to the major realizations from that first mirror session. These insights and awareness continue to solidify the growing comfort and gratitude for my body.

But this comfort and gratitude are continually challenged, often unexpectedly. Near the end of stay in hospital, I had finished my morning workout, taken a quick shower, towelled dry, and wrapped the disappointingly tiny hospital towel around my waist. I studiously avoided dropping my gaze low enough to risk seeing my bare chest. I stood with my back to the bathroom mirror and reached down for my stack of clean clothes. And I realized – in a heart-pounding moment of fear and curiosity, shame and acceptance, annoyance and awareness – that I was still cheating. So I straightened up and, in a clumsy bathroom pirouette with a frayed white-towel skirt, I turned around to the face the mirror without a shirt or bra.

I had not been able to tolerate the sight of my bare chest since I was in my early teens. When I turned around that morning, my eyes initially focused only on my face and arms and shoulders – anatomy which was comfortably familiar after previous mirror sessions – dancing deliberately away from the lower half of the mirror.

Still cheating.

So I forced my focus downwards and inwards. And – to my complete astonishment! – I felt only the mildest discomfort. I saw the unwanted female breasts. I felt disappointed by their presence. But behind them, I also saw the power in my pectoral muscles and I saw the gentle rise and fall of breaths moving through my chest.

Certainly, the presence of breasts was uncomfortable and undesirable. And if I could have snapped my fingers and created a flat male chest just like that, I would have done so without hesitation. But I knew that was impossible. And I know that getting a mastectomy will be a long, painful, and potentially expensive process that is also impossible in any short-term timeframe. So that moment of seeing my naked chest in the mirror helped me achieve a radical acceptance of those impossibilities and a neutral peace with my current reality.

I may decide to pursue top surgery in the future, but that choice – previously motivated by disgust and self-loathing – became less urgent and less desperate as I stood in front of the mirror. I am now less convinced that top surgery will ultimately be necessary, but I will be open to that option moving forward. I will also be open to this ongoing process of accepting what’s real and revising what’s ideal. And I will remain open to any further insights that my capricious mirror image chooses to share with me.

The time will come when, with elation you will greet yourself arriving at your own door, in your own mirror and each will smile at the other’s welcome – – Derek Walcott (Love After Love, from Collected Poems 1948-1984)

In a previous post, I mentioned that I used to draw. Most of my earlier artwork was done during high school from 2006 – 2008. I usually drew animals. I preferred colored pencils. I reluctantly tried different styles and different drawing materials (pencil, acrylic paint, watercolor, charcoal, ink etching) for art class assignments.

High school art class deadlines forced me to keep drawing frequently for three years, but after graduation I only finished a handful of pictures. Eventually, I completely stopped drawing. Art was simply too frustrating and too painful for me to continue. I was too perfectionistic for the process to ever be enjoyable. I would get so angry while drawing that my family often had to physically restrain me from tearing my work to shreds. Before I ever started a picture, I spent hours drawing a 1cm by 1cm grid on the reference photo and enlarging the grid proportionally on the blank white paper so that I could copy each detail meticulously. After the grid was complete, the drawing process felt like a never-ending series of mistakes that required constant erasing and smudging and adjustment. So I hated drawing. But I felt compelled to do it because I received so many compliments on the end results.

My last attempt at drawing was during second year vet school in 2011. It was a picture of a cow and her calf, shown above, intended as a gift for one of my professors. I became so enraged halfway through the drawing that I tore up the reference photo and threw my box of colored pencils across the room. After cleaning up the scattered paper fragments and shattered rainbow lead, I stuffed the half-finished picture back in a folder and promised myself I would never draw again. That drawing will remain forever incomplete. And I was artless for the next five and half years.

In all my previous artwork, I had never drawn people. Partly because I assumed I would never have the skill to draw a person perfectly. But mostly because I was so uncomfortable with my own appearance – discomfort arising from gender dysphoria and resulting in anorexia – that I refused to consider any attempt at drawing a human face or body. But I harbored a secret desire to be able to draw portraits with enough skill to capture a person’s resemblance and facial expression.

During my time on the psychiatric unit over the past few months, I finally decided to try drawing again. But I knew I had to do something differently to avoid returning to the same frustrating perfectionistic habits. And following the radical improvements in body image, I wondered if I could now try drawing people. So I broke all my old rules.

No pencil. No eraser. No grid. No animals.
Human faces. Drawn freehand. With pen.

This process has been far more enjoyable than I ever imagined. I now find myself looking forward to drawing with more excitement that I ever believed would be possible for me. I think my portrait efforts are a reflection of my progress in creating a more positive perception of my current appearance. And, in some ways, these portraits have been very helpful in contributing to acceptance and appreciation for human faces, including my own.

My drawings have become an incredibly important aspect of how I cope with body dysphoria, so I will start posting them here on Genderland. This ongoing active acceptance of my appearance is a process that will remain forever incomplete.

“Every portrait that is painted with feeling is a portrait of the artist, not of the sitter.”– Basil Hallward (The Picture of Dorian Gray, Oscar Wilde, 1890)

————Part 1: Recognizing an Optical IllusionPart 2: Deconstructing an Optical Illusion~ Part 3 in the Ambiguous Androgyny series ~
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Following the radical shifts in perspective after the mirror experiment, I have been working through several new considerations.

The first consideration is an important caveat: all of these recent realizations – a more positive and more realistic body image, a concrete image of my ideal body to help guide transition choices, and increased gratitude and acceptance for my body – all of these realizations apply very specifically to my body as it currently exists. Had I attempted that mirror experiment at any other time over the past 10 years, I think I would have aborted the attempt within a few minutes because the disgust, self-loathing, and confusion generated by seeing my mirror reflection would have been intolerable.

But now, I am fitter, stronger, and physically healthier than I have ever been before. This is not to suggest that accepting your body is only possible if you meet externally imposed standards of fitness or conform to conventional expectations of attractiveness. Absolutely not. I am only saying that the increased muscularity and decreased body fat associated with a rigorous exercise routine are changes that have allowed me to finally feel comfortable in my own body.

This also is the first time that I have achieved a degree of androgyny sufficient to alleviate most of my physical dysphoria while also maintaining a healthy body weight. This is not to suggest that expression of androgyny excludes bodies that are thinner or heavier than mine. Absolutely not. I am only saying that finding a way to create a comfortably androgynous appearance for myself, without resorting to a dangerously low body weight, is a much healthier and more sustainable approach than my teenage anorexia.

I think it is also important to acknowledge that much of my gratitude for my current body comes from realizing that I have won the genetic lottery. As an XX individual, I consider myself incredibly lucky to have a body that is capable of looking this androgynous without medical or surgical intervention so far. I have made considerable effort, through my workouts and my diet and my clothing choice and my haircut, to create this appearance. But that effort is only one small part of the story. I am lucky that I have the metabolism to lose weight relatively easily and maintain low body fat. I am lucky that I have the anabolic capacity to build muscle mass fairly easily in response to the effort I put in at the gym. I am lucky that my facial features are naturally androgynous. I am lucky that my chest has always been flat and has become even flatter after thousands of pushups and thousands of bench press reps. I cannot take credit for those factors. I can only be grateful for them.

The second consideration is that maintaining my body in a way that feels comfortable for me will require consistent ongoing effort. I have several options about what kind of effort this might be. I could continue my current diet and exercise routine. I could proceed with medical options including testosterone and mastectomy. I could work towards greater internal acceptance of the aspects of my body that I cannot control. All of these possibilities represent ongoing effort. All of these options come with advantages and disadvantages.

My daily workouts require a considerable investment of time and energy. Having started a new combination of medications to manage the debilitating fatigue of depression and having adjusted my lifestyle to incorporate an early morning exercise routine, the time and energy costs are no longer prohibitive barriers.

My diet requires constant awareness of calories, grams of protein, grams of fat. My diet also requires active tolerance of the often intrusive nature of this awareness. Many of my food-related thoughts and behaviors are habits deeply ingrained from a decade of disordered eating, and I do not recommend these strategies to anyone else. But I have accepted that these thoughts and behaviors are unlikely to disappear entirely. And while I don’t think the improvements in body image will lead to any immediate changes in my approach to food, these thoughts and behaviors become much more tolerable in the context of acceptance and gratitude instead of disgust and self-loathing.

Now that my ideal body is more clearly defined in my mind, I feel better able to evaluate the many different options for testosterone moving forward. Because I have realized that my goal is not complete physical masculinization but rather minor masculinizing adjustments to my current body, I think I would prefer to start on a low dose of testosterone so that physical changes occur very gradually. At this point, I have one particularly prominent question: In an XX person, would long-term administration of low dose testosterone ultimately lead to complete physical masculinization, but at a much slower pace than higher doses of testosterone? Or would long-term administration of low dose testosterone lead to partial masculinization that would be sustainable and non-progressive past a certain point? I am hoping very strongly for the latter. I have started looked for published data to answer this question, but so far I have only found articles describing the effects of chronic administration of high doses of testosterone in FTMs or describing the effects of short-term administration of low doses of testosterone in women (including the effects of exogenous testosterone administered to treat various medical conditions as well as the effects of endogenous testosterone in women with polycystic ovarian syndrome). However, there seem to be no studies describing the effects of long-term administration of low dose testosterone in female-bodied people without concurrent medical issues. I have only found a handful of anecdotal descriptions on personal blogs from trans people taking low doses of testosterone. But this is an important question for me, so I will continue my investigation.

The third new insight is that greater acceptance and comfort with my how my body LOOKS has been followed by much greater awareness of how my body FEELS. Prior to the mirror experiment, I was so detached from my body that I had very little awareness for how it felt. When prompted by my psychiatrist to identify physical sensations associated with certain emotions, I was completely unable to do so. The only time I ever felt any meaningful physical awareness was during exercise, as I have described with respect to running and boxing.

But since that mirror experiment, I seem to have developed an intensely heightened awareness of so many daily physical sensations. A shower used to be just a shower. Now a shower is a thousand individual drops of water, each one hitting my skin and trickling down my body. Applying hand lotion used to be just a necessary task. Now I am aware of how the knuckles and metacarpals and tendons of one hand feel inside the palm of my other hand. Clothing used to be just a set of pants and shirts and underwear. Now I am aware of how different types of fabric feel against my skin, aware of the pressure as a shirt stretches across my shoulder, aware of the gentle tension of cuffs around my wrists. Going outside used to be a retinal adjustment from dark hallway to sunny doorway. Now this transition is not just a visual adjustment but also a physical awareness of the change in temperature from hallway to door, an awareness of how the shadows feel when they dance across my skin as the sunshine chases them away. Waking up in the morning used to be an abrupt termination of a dream replaced by real-life thoughts. Now waking up is an immediate awareness of my whole body stretched out on the mattress, an awareness of the light weight of sheets and blankets surrounding me.

“You used to be much more… muchier. You’ve lost your muchness.”– The Mad Hatter (Alice’s Adventures in Wonderland, 1865)

I really can’t describe this feeling any better than The Hatter. Being inside my body now is much more muchier. There’s so just much muchness.

I had been living with my parents before I was admitted to hospital but was unable to move back in with them after discharge, so one of the priorities was finding a place to live after discharge. Up until the mirror session, I had been thinking only in terms of apartments and rent and location. But now, I finally understand that I can live HERE, in my own body. It feels like authentic inhabitation of a home I didn’t even realize that I had.

The last new realization is also the most powerful. I previously described watching how women shift their interpretation of my appearance from male to female when they see me in public washrooms. I recently had the opportunity to observe this perceptual reversal in a dentist’s waiting room instead of a womens’ washroom.

I sat down in the waiting room to fill out a general history form, which required that I list my current medications. An elderly man sitting nearby saw me writing and said, “Whattaya doin’? Writin’ down the names of all your girlfriends?” His tone and posture seemed to suggest that he was making a conspiratorial joke, but I did not find his questions humorous at all. I was annoyed by the interruption, astonished by his presumption, and curious about his assumptions.

I was wearing jeans and a loose-fitting blue sweater, with my backpack on the floor beside me. I thought it most likely that his attempted joke hinged on the string of assumptions that I am male, straight, teenage, and obsessed with girls. I also considered the possibility that he perceived me as female and assumed that I am lesbian because I have short hair. I won’t list all the problematic stereotypes associated with those assumptions, but I will say that I have encountered all of them on multiple occasions before.

I continued writing without looking up from the page, and said, “No, I’m writing down my medications.” And then, because I was both intensely curious and intensely irritated, I looked up and asked him, “Do you think I’m male or female?” He frowned, and I watched his eyes roam up and down my body, eventually returning to my face. He finally said, uncertainly, “Ooooh… I guess… you’re actually female?” So it seems that he had indeed made that first series of assumptions: male + straight + young = girl-crazy. And while his assumption that I was a boy provided some validation of my physical androgyny, his comments also demonstrated incredible ignorance. So I shrugged, unwilling to definitively confirm either maleness or femaleness. But because he now saw me as female, I said, “Doesn’t mean I don’t have girlfriends.” He let out a short uncomfortable chuckle, and then stood up and moved to the chair as far away from me as possible.

And you know what? I did not feel the slightest hint of guilt about being the source of his discomfort. Nagging guilt about the discomfort that my appearance causes other people has plagued me in the past. But not anymore. Because I have achieved not only an authentic inhabitation of my body, I have also achieved an authentic acceptance of my ambiguous androgyny.

This here? What you see when you look at me?
This is not a deliberate deception.
This is not an intentional illusion.
It is authentic ambiguity.

It is not a palmed card.
It is not a crafty shuffle.
It is not a false cut.
It is an ace worn proudly on my sleeve.

“So come close. Get all over me. Because the closer you think you are, the less you’ll actually see.”– J Daniel Atlas (Now You See Me, 2013)

————Part 1: Recognizing an Optical Illusion ~ Part 2 in the Ambiguous Androgyny series ~Part 3: What You See
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“Are you watching closely?”– Alfred Borden (The Prestige, 2006)

In my last post, I discussed how the analogy of an optical illusion – specifically, the multistable perception that arises when viewing ambiguous images – has given me a more concrete framework to understand my experience of body dysphoria. Optical illusions have been described as an experience where “expectations are violated”, so I had challenged myself:

Does this multistable perception of my mirror image indicate the presence of some problematic expectations that my ambiguous androgyny somehow violates? Is it possible for me to deconstruct this distressing optical illusion to create a more comfortable, more coherent, and more stable cognitive interpretation of my physical appearance?

Certainly, part of the optical illusion effect comes from gender dysphoria itself. The inexplicable but undeniable distress I feel in response to seeing my female anatomy, and the detachment from my physical appearance that developed as a means to cope with that distress, both contribute to difficulty recognizing my mirror image as an accurate reflection of myself.

But now I think there was a second layer to that illusion: my own expectations about what male and female bodies are supposed to look like. My physical androgyny, deliberately designed to minimize female traits and partially successful in reducing the intensity of body dysphoria, became an optical illusion because it did not match conventional expectations of “male body” or “female body” and generated mutually exclusive alternating interpretations of “boy” or “girl”. “The perception of multistable stimuli can be influenced by contextual properties of the image, including recognizability and semantic content.” (Leopold 1999) My ambiguously androgynous mirror reflection became an illusion by violating my gendered-body expectations and refusing to align with any recognizable gender pattern in my mind.

Which leads to the third layer of this illusion: the insidiously deceptive illusion of opposites. For so many years, I assumed that because my brain did not expect to see a female body, it must expect to see a male body instead. This was an appealing and self-reinforcing assumption because a “male” body is a concrete and easily visualized image. Dozens of male bodies cross my sightline each day. My mind catalogues all their physical similarities, an additive assimilation of biased data to create an increasingly narrow idea of what makes a man a man. This process provoked a constant self-loathing comparison of my female body to their male bodies and a vicarious idealization of stereotypical physical masculinity.

A couple of months ago, I had several long conversations about my ongoing disordered eating issues and my experience of body dysphoria with a new acquaintance. When I described the optical illusion effect associated with seeing myself in the mirror, he asked, “Would it be helpful to spend longer looking at yourself in the mirror, to try to acclimatize your mind to the mirror image?” I immediately dismissed his suggestion, telling him that spending more time in front of the mirror would only prolong the uncomfortable optical illusion sensation.

But over the next few days and weeks, I found my mind continually returning to his question. Everything I hear, every word I read, everything I see – all of it, all the time – it just keeps echoing around in my brain like a constant cognitive echolalia. Questions always echo loudest.

“Would it be helpful to spend longer looking at yourself in the mirror?”

“…spend longer looking at yourself in the mirror?”

“…yourself in the mirror?”

I started to reconsider my original dismissal. I tried to imagine spending a longer period of time in front of the mirror. Anticipating the same discomfort and confusion that has always plagued my reflection, I remained rigidly resistant to this prospect. Until I finally realized: I don’t need to look at my reflection LONGER, I need to look at it DIFFERENTLY. I should stop trying to force the optical illusion into a logical conclusion. Instead, I need to try to see past the deception and reveal my brain’s expectations. I should stop letting myself get distracted by the magician’s misdirection, lulled over and over into seeing the impossible while knowing that it is impossible. Instead, I need to ignore the magician’s diversions and focus on the cold hard mechanics of the trick to see how it’s actually performed.

So began the mirror experiment. With an odd mixture of anxiety and curiosity, I propped myself cross-legged on the stainless steel shelf across from the mirror in my hospital bathroom. I stared at myself in the mirror for an hour.

The first few minutes in front of the mirror were dominated by self-judgment. I felt so obnoxiously vain – with respect to Greek mythology, such intense focus on my reflected image is practically the definition of narcissism. But I was able to rationalize it by reminding myself that someone else had suggested this mirror experiment. After I let go of that self-judgment, the insights that arose during my time in front of the mirror were incredibly enlightening and completely unexpected.

As I stared at my reflection, I intentionally kept changing the lens through which I viewed my mirror image. I started with a third-person lens, trying to see myself neutrally, objectively, as an outsider. I wondered: What does my psychiatrist see when he looks at me? What do my friends see? What do strangers see? I revisited echoes from previous conversations, comments other people had made about my physical appearance.

“I see you as female right now because I’ve read your file and I know your age. You’re 24. But you don’t look like a 24-year-old man… probably based on the lack of facial hair. So if I just saw you on the street and didn’t know your age, I would assume you were an adolescent boy.” – a psychiatrist

“You think 80% of strangers read you as female and 20% read you as male? I dunno, McMurray… I think it’s closer to 50-50. Or maybe 60% would say you’re female, 40% male. There have been several times when we’ve had coffee where someone comes up to me after you’ve left and asked “Who was he?” or asked if you were my son.” – a friend

“Hey. I just wanted to say… you look so good in that tank top! Like, your shoulders are so jacked! Oh my god, I wish I had arms like that.” – an in-patient on the psychiatric unit

“Don’t take this the wrong way… but… your perception of yourself as ugly or unattractive is not exactly accurate… I think that might be an unrealistic and negative distortion. At least from my perspective.” – an acquaintance

Hearing those echoes and seeing the person in the mirror through this third-person perspective was like seeing an engaging snapshot of a stranger, appreciating their appearance and finding yourself curious about who they are and what their life is like. Such strict objectivity was surprisingly reassuring.

I mentally hit ⌘S to save an image of that objective snapshot, then discarded the third-person lens, toggled the microscope, slotted in a first-person filter, and reattached my “self” to the body in the mirror. As my first-person perspective came into focus, I felt the familiar flutter of distressing dysphoric confusion, but I hit ⌘S again. Then I opened up two Preview windows side-by-side to compare the third-person and first-person images.

Prior to this mirror session, I didn’t think that I had a distorted body image. I thought I saw myself realistically and just didn’t like what I saw. But this direct comparison of two different perspectives on my appearance illuminated several previously unrecognized negative distortions. I am not actually not as homely as I always thought, I am leaner and more muscular than I thought, I look physically fit and healthy. These realizations came with a deep sense of gratitude for my body and a brand new desire to treat this body kindly, no matter which gender its appears to be.

This direct side-by-side comparison also revealed a troubling cognitive sleight-of-hand: whenever I see myself, my mind immediately hones in on female anatomy and magnifies the size and significance of these female features while largely ignoring other aspects of my appearance. Being able to see myself in the third-person image without the mentally Photoshopped enhancement of physical femininity finally allowed me to appreciate how small and insignificant these female anatomical traits are on my own body.

The next step was to return to the original challenge I had set for myself: examine my expectations. I adjusted the microscope once more, retaining the first-person lens but changing the position of the focus to visualize the expectations underlying the outward appearance. It’s obvious that I do not expect to see a female body in the mirror, but do I really expect to see a male body instead? That’s an easy assumption, but is is accurate?

I have struggled for so long to create a tangible idea of my transition goals. Considering making masculinizing modifications to my body has always seemed appealing, but those options come with risks and side effects and I have been unable to clearly visualize the final outcome of these steps. So I have been overwhelmingly uncertain to what I extent I want to medically transition.

With the focus on my expectations, I opened up a third window in my mind: a CGI animation program. I imported the objective third-person image of myself and translated that into a 3D avatar that represents my current body. Then I started building an avatar to represent my “ideal” body. To do this, I had to disable the program’s automatic preset templates for “male” or “female” characters – templates generated from internalized expectations of what “men’s bodies” and “women’s bodies” are supposed to look like, expectations accumulated after nearly two and a half decades in a world that revolves around binary gender stereotypes. Without a 2D image or a preset template, I had to start from scratch on my “ideal” avatar, first building a basic genderless human body and then adding and subtracting anatomical features (a beard, a penis, a square jaw), adjusting ratios and proportions (broader shoulders, bigger deltoids, narrower hips), until my “ideal” avatar finally emerged with a startlingly concrete clarity. My “ideal” body seems to be one of nearly symmetrical androgyny: a lean and physically fit individual with moderate upper body muscle mass (prominent but not bulky), a smooth chest, a shoulder-to-hip ratio of about 1.2 to 1.4, a waist-to-hip ratio of about 0.8, and a well-defined jawline. Beard and penis not required.

Having created realistic 3D models of my current body and my “ideal” body, I aligned these two avatars side-by-side on the screen. I reduced the opacity of both images to about 50% transparency and dragged the “ideal” avatar over top of the “current” avatar. And then I looked for discrepancies, trying to figure out where the two avatars differ. To my astonishment, it became clear that the differences between my real body and my ideal body are far more minor than I had previously believed! My ideal body has a slightly more masculine silhouette than my current body (broader shoulders, more upper body muscle mass, wider waist, narrower hips) and slightly more masculine facial features. Otherwise, my real and ideal avatars are almost identical.

This realization was profoundly reassuring. I finally have a concrete mental image of what I want my body to look like in the future – I have an avatar to project forward in time. I also have a much more positive and more realistic perspective on my current body, a much more authentic acceptance of my current appearance, and an overwhelming gratitude for my body. My androgynous appearance no longer seems ambiguous, because I no longer have to force it to align with expectations about what men and women look like. My androgynous appearance is now unambiguously, unequivocally, unashamedly my own. “In addition to being associated with perceptual transitions during multistability, activity in frontal and parietal cortex can also contribute to percept stabilization.” (Sterzer 2009) I think these cognitive contortions through the looking-glass have finally stabilized my perception of my mirror image in a way that could be comfortable and consistent over time.

My mind lingered for a few more moments, visualizing my real and ideal avatars, regarding them both with dawning respect and gratitude and affection, feeling a growing groundedness inside these bones and vessels and muscles that are my home for life. And then, ⌘S one more time – these images are worth saving, remembering, cherishing – one by one I closed all the windows I had opened in my mind. After the software was shut down, the microscope dismantled, the lenses stowed away, I found myself with nothing left between me and my mirror image. And it was in that one raw unguarded moment that I realized: I DON’T WANT TO KILL HER. I had just spent a very intimate hour with this girl – I had seen every subtle change in her expression, seen tears of gratitude welling up, watched a bemused little grin flicker across her face, I had watched her body shift and stretch, had seen the athletic strength and flexibility behind even the smallest adjustments in posture – and I could not bear the thought of killing her. Reattaching my “self” to that thought, I realized: I DO NOT WANT TO KILL MYSELF. More than two years of suicidal ideation – varying in urgency and intensity but relentless in its constant haunting presence – evaporated in that single second. Just like magic.

“Every great magic trick consists of three parts or acts. The first part is called The Pledge. The magician shows you something ordinary: a deck of cards, a bird, or a man. He shows you this object. Perhaps he asks you to inspect it to see if it is indeed real, unaltered, normal.

The Pledge is my female body: real, ordinary, medically unaltered.

The second act is called The Turn. The magician takes the ordinary something and makes it do something extraordinary. Now you’re looking for the secret… but you won’t find it, because of course you’re not really looking. You don’t really want to know. You want to be fooled.

For years, my brain was stuck at the Turn, constantly creating illusions without really looking, desperately wanting to fool itself into seeing a body that matched my unchallenged expectations. I finally made those expectations disappear.

But you wouldn’t clap yet. Because making something disappear isn’t enough; you have to bring it back. That’s why every magic trick has a third act, the hardest part, the part we call The Prestige.” – Cutter (The Prestige, 2006)

And now I’ve brought something back: a realistic perception of my female body, stripped of illusion and expectation, gently wrapped in gratitude and acceptance.

————~ Part 1 in the Ambiguous Androgyny series ~Part 2: Deconstructing an Optical IllusionPart 3: What You See
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Despite my detailed descriptions of the anatomic dysphoria associated with gender dysphoria, it has remained very difficult for me to explain my experience to other people in a way that is concrete and understandable to them. But the process of putting words to a such a vague yet distressing combination of thoughts and emotions has been extremely helpful for me, because it forces me to analyze my own perspective in a way that makes it more clearly defined in my own mind.

Anatomic dysphoria is often portrayed as the distress arising from a mismatch between physical attributes and an intrinsic cognitive “gender identity”. In a previous post, I described the problems with the concept of “gender identity” and argued against the idea that “gender identity” is an inborn, innate, and immutable property. So “gender identity” does not serve as a useful means of understanding my own experience. I have continued searching for other ways to conceptualize my physical dysphoria.

Re-reading previous posts on this blog and reflecting on the language that I use to describe my experience to others, I noticed that I commonly return to the analogy of an optical illusion:

“An accidental glimpse of this girl-face in the mirror feels like a baffling optical illusion, an odd reflection of a face I know so well but can never quite call my own.”

“I continue to stare at those reflections and images of myself with the unsettling mixture of curiosity, frustration, and disorientation that comes with trying to unravel a particularly puzzling optical illusion.”

I have also described the rapid and involuntary shifts in perception that occur when I view my physical image:

“I have entered an ambiguous time in my transition. Like the color of the tiles in the checker shadow illusion, how my gender is perceived is often entirely context dependent… When I look in the mirror, sometimes I can see two different versions of myself, depending on which cues I focus on. When I focus on the cues that my brain interprets as ‘male’, I can see myself as I know myself to be, every week more aligned with my internal self-image. When I focus on the cues that my brain interprets as ‘female’, I feel dysphoric and upset.” – It Doesn’t Have to Be This Way

“Every day, my face looks different… The feeling invoked when I look in the mirror is the same as when I view these [optical] illusions. They are confusing, disorienting, and unsettling. To me, these emotions are the defining characteristic of body dysphoria.” –Amy Dentata

In light of my personal experience and these sporadic references from other trans writers, I expanded my investigation of optical illusions. The results of my research suggest that using the analogy of an optical illusion to describe my experience of body dysphoria is extremely accurate.

One particular optical illusion that is especially relevant to my experience is the image called My Wife and My Mother-in-Law. This illusion closely aligns with my experience of anatomic dysphoria because it generates two very different interpretations of a human face based on unchanging physical features. The photo at the top of this post is my own drawing of this well-known illusion.

I recently used My Wife and My Mother-in-Law to help explain my experience of physical dysphoria to my psychiatrist. He admitted that he had seen the image before, but prior viewing does not detract from my explanation. I asked him what he saw when he looked at the picture. He said that his first impression is that of a young woman with her face turned away, but because he knows that an old woman’s face is also there, he can intentionally re-interpret the image to visualize the old woman. (The young woman’s chin becomes the old woman’s nose, and the young woman’s necklace becomes the old woman’s mouth). I asked him what he felt while looking at that image and seeing the young woman’s face alternate with the old woman’s face. He said he felt a brief and mild sensation of confusion and discomfort, but his mind naturally reset the lines back into the young woman’s face which restored a more neutral emotional response to the image. I explained that for me, the image never settles on one face or the other for very long, it constantly shifts back and forth between the young woman and the old woman, which makes the viewing experience very disorienting and confusing. Then I told him, “Imagine that the image doesn’t shift between young woman and old woman, but instead shifts between young woman and young man. Over and over and over. Imagine that the image never settles into a consistent comfortable interpretation. Imagine that you see this constantly alternating image every time you look down at your body, every time you look in the mirror, every time your reflection stares back at you from a cell phone screen or a darkened store window. Imagine that. That’s what my physical dysphoria is like, an optical illusion where my real image (young woman) and my brain’s expected image (young man) are constantly competing and my perception of the image is constantly changing to align with one or the other. I end up feeling disoriented and unsettled and completely detached from my own body.” He considered this – very carefully, very thoughtfully, as is his way – and then nodded. He truly seemed to have an accurate and empathetic understanding of my experience of anatomic dysphoria.

My Wife and My Mother-in-Law belongs to the class of optical illusions known as ambiguous images. (Podvigina 2015) Examples of other ambiguous images include the Rabbit Duck, Rubin’s Vase, Necker’s Cube, Winson Figure, and Spinning Dancer.

Many types of optical illusion create a perceived image that differs from the actual components of the figure based purely on the physical properties of the visual stimuli itself, properties such as shape, texture, contrast, and continuity of lines. These are often called literal optical illusions. Ambiguous images differ from literal optical illusions because the visual stimuli of ambiguous images allow multiple coherent cognitive perceptions to arise from the same image components. Literal optical illusions create a single inaccurate perception. Ambiguous images create multiple spontaneously shifting accurate perceptions – this experience is called multistable perception.

Multistable perception occurs when a static sensory stimulus is ambiguous and consistent with two or more mutually exclusive subjective interpretations; each interpretation is discrete and stable for a short period of time, but perception alternates between these different interpretations. (Leopold 1999, Eagleman 2001, Sterzer 2009, Schwartz 2012, Podvigina 2015)

[Note: multistable perception can occur in response to visual, auditory, olfactory, and tactile stimuli, but this phenomenon has been most extensively investigated with respect to visual sensory input. (Schwartz 2012) The rest of this post will focus exclusively on multistable perception in a visual context].

Characteristics of multistable perception include:

Exclusivity: conflicting visual representations alternate but are never simultaneously present. There is no “average” or “combined” interpretation. (Leopold 1999, Schwartz 2012)

Inevitability: alternations in perception are initiated spontaneously. (Leopold 1999, Schwartz 2012) The alternation process cannot be completely prevented, but alternations in perception are subject to limited voluntary control and may be influenced by the intention of the observer; control over the rate of perceptual alternation and stability of each percept improves with practice. (Leopold 1999, Sterzer 2009, Podvigina 2015)

Randomness: durations of successive intervals of transiently stable percepts are unpredictable and characterized by sequential stochastic independence. The statistical properties of multistable alternations show similar distributions of dominance phases (which percept is dominant) across different types of stimuli and between individuals. (Leopold 1999, Schwartz 2012, Podvigina 2015)

Dependence on awareness: perceptual reversals are very rare or even absent when observers do not know that alternative interpretational possibilities exist. (Podvigina 2015)

These traits of multistable perception also characterize my experience of anatomic dysphoria:

Exclusivity: conflicting interpretations of my physical appearance seem to alternate but are never simultaneously present. I have been unable to achieve any consistent “average” interpretation of my physical features. My androgyny seems to be its own form of ambiguous image: androgynous ambiguity is consistent with two mutually exclusive interpretations – male and female – leading to multistable perception in my mind.

Inevitability: these alternations in perception are initiated spontaneously. I cannot prevent them from happening whenever I see my body or my mirror image. I have limited voluntary control over which perception is dominant at any point in time.

Randomness: the rate of alternation between conflicting perceptions of my physical appearance seems to be unpredictable and variable, which makes the experience confusing and unsettling.

Dependence on awareness: perceptual reversals are very rare or even absent when observers do not know that alternative interpretational possibilities exist. I am constantly aware of multiple interpretations of my own appearance, so this trait is more obvious when I consider other people’s perceptions of my appearance. In situations where other people initially assume that I am either male or female, perceptual reversals occur only when the situational context later indicates that their interpretation of my sex may be inaccurate. The best example of this is when I’m standing alone in a public womens’ washroom. When women enter the washroom and first see me, their facial expression often indicates surprise (and sometimes alarm) because they interpret my appearance as male. Occasionally they ask me if I’m in the right washroom, but more often they step outside the washroom, check the sign on the door, and then, having confirmed that they are in a space designated for females only, they re-enter the washroom and re-evaluate my appearance. Now that they are aware of an alternative interpretation of my appearance, their facial expression shifts towards relief and acceptance as their mind realigns my features in a pattern recognizable as female. The Women’s Washroom Double-Take used to make me feel guilty for making someone else feel uncomfortable, but now generates more neutral interest as I observe their perceptual reversals in real-time.

“Ambiguous figures provide the experience of having one’s perceptual awareness switching between different options while at the same time remaining fully conscious that no physical stimulus change whatsoever underpins these vivid perceptual changes.” (Kleinschmidt 2012) This statement from an article reviewing the literature on multistable perception bears striking similarity to previous description of my own experience: “My appearance seems to change dramatically within the space of just a few minutes or hours… My image remains familiar and recognizable, but constantly different… I know with certainty that it is not physiologically or anatomically possible for any human body to change that much in such a short period of time. I know this. I remind myself of that over and over. Yet what I keep seeing with my own eyes, right there in front of me, incontrovertible visual evidence, is this shape-shifting mirror-ghost of a body that I cannot imagine I actually inhabit.”

Unlike many optical illusions which create illusory perceptions primarily due to deficits in the visual system, ambiguous images (a form of multistable stimuli) are unique in allowing neural activity related to subjective conscious perception to be distinguished from neural activity related to objective physical stimulus properties. (Eagleman 2001, Sterzer 2009, Schwartz 2012) Evidence from several lines of empirical neuroscience (including functional magnetic resonance imaging and transcranial magnetic stimulation in humans and non-human primates) suggests that continuous processes in the frontal and parietal cortex are involved in constantly re-evaluating interpretations of sensory input and initiating changes in subjective perception, which results in the rapid and spontaneous perceptual alternations characteristic of multistable perception. (Leopold 1999, Sterzer 2009) These processes occur unconsciously during normal vision (almost all visual stimuli contain some degree of ambiguity that is rapidly and accurately resolved by this processing). This re-evaluation of perception only becomes consciously apparent when ambiguities in visual stimuli are maximized. (Leopold 1999, Eagleman 2001, Sterzer 2009) Multistable perception thus appears to be one component of an adaptive global process that generates a unified and coherent interpretation of the world, even though the information available to interpret is often fragmentary, conflicting, or ambiguous. (Sterzer 2009, Schwartz 2012) Multistable perception represents a kind of “stable instability” in subjective interpretation. (Schwartz 2012) And it seems that physical androgyny represents a particularly ambiguous image that is difficult for many people – myself and others – to interpret coherently.

The experience of multistable perception shows considerable individual variability. The rate of perceptual fluctuation tends to be consistent for a given person but varies by as much as an order of magnitude from one person to the next. (Leopold 1999, Schwartz 2012, Kleinschmidt 2012) Individual variation in the rate of perceptual alternation is associated with genetic factors, differences in brain structure (particularly in parietal lobe regions), and personal attributes including intelligence, creativity, and even mood disorders. (Leopold 1999, Kleinschmidt 2012, Podvigina 2015) Not only are there large individual differences in perceptual switch rates, there are also individual differences in preference for one percept over another – the preferred (dominant) interpretation of an ambiguous image is observed for a longer duration than the non-dominant interpretation over a period of spontaneous perceptual alternation. (Podvigina 2015) Certainly my personal experience aligns with this data. From my conversations with others regarding My Wife and My Mother-in-Law, it seems that I experience a much faster rate of perceptual reversal than most people: for me the image fluctuates very rapidly between the young woman’s face and the old woman’s face, while others describe something similar to what my psychiatrist described where perceptual switches occur less frequently and are more dependant on deliberate effort. It also seems that I experience less pronounced perceptual dominance than most people: I usually see the old woman’s face on first glance but during subsequent perceptual alternation it doesn’t feel like either face represents a more stable observation, while others generally describe that the perception of the young woman’s face is heavily dominant. So I wonder: do my individual characteristics associated with more rapid perceptual alternation and less pronounced perceptual dominance in response to multistable visual stimuli also contribute to my rapid shifts in perception and my difficulty maintaining a consistent interpretation of my own mirror image?

I think the optical illusion analogy is very valuable to help explain my experience of physical dysphoria. I have now refined this optical illusion analogy to refer more specifically to multistable perception that arises in response to viewing ambiguous images (particularly ambiguous images involving human faces). This new framework supports discussions with other people on the topic of anatomic dysphoria, and also provides a more concrete scaffold for me to construct a better understanding of my own experience.

Al Seckel, formerly considered one of the world’s leading authorities on illusions, referred to optical illusions as an experience where “expectations are violated” (TED, 2004). On my journey through Genderland thus far, I have radically re-evaluated personal and cultural expectations that I previously took for granted. I have deliberately distanced myself from restrictive and oppressive societal gender stereotypes and expectations. But now, I think I need to challenge myself even further. Does this multistable perception of my mirror image indicate the presence of some problematic expectations that my ambiguous androgyny somehow violates? Is it possible for me to deconstruct this distressing optical illusion to create a more comfortable, more coherent, and more stable cognitive interpretation of my physical appearance?

“As much as I’d like to believe there’s a truth beyond illusion, I’ve come to believe that there’s no truth beyond illusion. Because, between ‘reality’ on the one hand, and the point where the mind strikes reality, there’s a middle zone, a rainbow edge where beauty comes into being, where two very different surfaces mingle and blur to provide what life does not: and this is the space where all art exists, and all magic.”
– The Goldfinch (Donna Tartt, 2013)

I have spent much of the past two years researching gender dysphoria and exploring what it means to be transgender. This process has often been frustrating and confusing, as I have had considerable difficulty reconciling my intense physical dysphoria related to the female aspects of my body with the absence of any internal sense of “gender identity”. But after this prolonged immersion in the online trans community, in-depth review of the scientific literature on trans issues, and personal experience with transgender support groups and mental health professionals, the most prominent source of my chronic confusion has become apparent.

The “gender identity” concept, typical transgender narratives, and the criteria for diagnosis of gender dysphoria all depend on gender stereotypes – stereotypes which are increasingly irrelevant in modern society and which research overwhelmingly suggests are cultural constructs with limited biological underpinning. “One of the first steps to liberating people from the cage that is gender is to challenge established gender norms.” (Reilly-Cooper 2016) I think the dependance of “gender identity” discourse, trans narratives, and gender dysphoria diagnostic criteria on these gender norms actually serves to reinforce outdated and restrictive stereotypes rather than dismantle or challenge those stereotypes.

Much of this post will directly quote statements made by other authors in scientific review papers or online articles (bold indicates my own added emphasis). My goal here is not to simply repeat what has already been so eloquently stated elsewhere. I refer readers to the sources referenced at the bottom of this post for more thorough discussion of various related issues.

Instead, I wish to organize these statements within a coherent framework. This framework demonstrates a troubling and self-reinforcing cycle: the concept of “gender identity” relies on problematic gender stereotypes, the typical trans narrative relies on “gender identity” as an explanation and justification for choices regarding transition, and the diagnostic criteria for gender dysphoria use conventional gender norms as the frame of reference for assessment and diagnosis. In a clinical context, trans people are thus motivated to present their experiences in a way that aligns with opposite-gender norms to facilitate diagnosis of gender dysphoria and gain access transition options. But aligning themselves with cross-gender stereotypes necessarily (and paradoxically) requires acknowledgment of the restrictive and oppressive nature of those stereotypes which are associated so strongly (but unjustifiably) with biological sex. To counter this contradiction, trans people then invoke the concept of a discrete and inborn “gender identity” to assert the legitimacy of their experience.

(Note: This is a lengthy post with dense content. However, my conclusions are carefully derived from in-depth analysis of the concepts and research outlined throughout this post, so I encourage readers to work their way through my arguments slowly and sequentially to fully understand my final conclusions).

(1) “Gender Identity” Concept

“Gender identity is a highly problematic concept.” (Hird 2003)

Typical trans narratives strongly emphasize behaviors and preferences that align with cross-gender stereotypes as evidence of an intrinsic “gender identity”, based on a faulty assumption that there are inherent qualitative differences between men and women to support the existence of those stereotypes in the first place. The conceptualization of “gender identity” as an innate internal property is the “crucial tension at the heart of gender identity politics”. (Reilly-Cooper 2016)

“In this research, ‘gender identity’ is characterized as a sense of oneself as male, female, or indeterminate, whereas ‘gender role’ is characterized as behaviors, personality traits, and interests that society applies to these aspects, and the way that people are measured against stereotypical attributes.” (Davy 2015) But is it really possible to separate “gender identity” from those “stereotypical attributes” that constitute “gender role”? To what extent do those “stereotypical attributes”, and the values and judgments that society assigns to those attributes, contribute to the development of “gender identity”?

I think “gender identity” is best understood as a constructed cognitive self-perception arising from internalized cultural gender stereotypes. “Gender variance may be conceptualized, as gender variant people apparently already do, as a multidimensional or sometimes idiosyncratically conceptualized, multicategorical construct.” (Cohen-Kettenis 2009) “It is clear from feminist research that behaviors are not intrinsically masculine or feminine, but change through time and in different spaces… Gender constructionist research suggests that biological imperatives are few in the human, and consist only of procreative imperatives. Other behavioral aspects such assartorial preference, aggression, empathy, and intelligence, among a number of other characteristics, are not sex speciﬁc and are often adaptable…recent research situates behavioral sex differences ﬁrmly within a social role model… This unresolved debate weakens any possibility of arguing that there is something inherent in masculine and feminine behaviors. (Trans) people have never been subjects of an independent masculine or feminine type, and combinations of what is deemed masculine or feminine at any one time can be found within all humans, albeit performed with different intensities.” (Davy 2015)

Indeed, research regarding the development of identity during childhoodconsistently describes “gender identity” as an aspect of self-perception that develops and evolves over time in response to many internal and external factors. Factors contributing to the construction of gender identity include genetics, hormones, socialization, and progressive cognitive understanding of gender. (Hines 2011, Reiner 2011) “Genderdevelopment is multidimensional, and developmental processes involved in each dimension are likely to differ.” (Hines 2011) Gender identity is an “evolving sense of self as one sex or the other.” (Reiner 2011) Evidence suggesting that “gender identity” develops and changes over time in response to many different factors directly contradicts the commonly held belief that “gender identity” is an innate and immutable property. The low rate of persistence of childhood gender dysphoria into adolescence also contradicts the idea that “gender identity” is an inborn and unchanging entity.

“Gender identity is woven pervasively throughout identity.” (Reiner 2011) It is also clear that “gender identity” is simply one of many facets of identity which develop over time. Therefore, “gender identity” cannot be regarded as something discrete and separate from overall identity, and “gender identity” cannot be regarded as immune to the internal and external factors contributing to the ongoing development of overall identity.

“The precise mechanisms of gender identity development are complex, the interactions of the mechanisms poorly understood, and the outcomes not entirely clear, except that children and adolescents nearly always dichotomize.” (Reiner 2011) This tendency to dichotomize “gender identity” reflects persistent societal adherence to opposing gender stereotypes. Gendered socialization and the influence of this socialization on cognitive understanding of gender are major factors contributing to the development of “gender identity”. “Socialization factors also gain in importance, as parents and then peers and eventually teachers encourage children to engage in gender-typed play. The child also begins to develop the understanding that he or she is male or female, and this knowledge produces motivation to imitate the behavior of others of the same sex.” (Hines 2011) As described above, this gendered socialization occurs despite the overwhelming evidence demonstrating that gender stereotypes have limited biological underpinning and that behaviors, preferences, personality traits, and cognitive functioning are not sex-specific attributes. (Hines 2011, Davy 2015) It is well established that societal gender stereotypes vary widely across different cultures and across different historical time periods (Hird 2003). This argues against any innate human “gender identity” giving rise to subsequent behaviors and preferences stereotypically associated with biological sex. Rather, it supports the idea that socially constructed gender norms give rise to individual “gender identity”.

I think the biggest weakness of the “gender identity” concept is that it is promoted as being real, immutable, and innate (endogenous) yet it remains so vague and poorly defined by those who claim to experience it. “The [trans] advocates’ websites rarely offer any indication of what feeling like a man or a woman is like.” (Davy 2015) Attempts to describe what “feeling like a man” or “feeling like a woman” means invariably fall back on conventional societal (exogenous) masculine or feminine stereotypes. This creates a frustratingly circular logic: “gender identity” is a property that is supposedly experienced internally (and therefore cannot be denied by an external perspective) but which cannot be defined in any way separate from externally imposed gender norms.

This has been extremely perplexing for me. This is why I have tried very hard to describe my experience of gender dysphoria in a concrete and clearly defined way that does not depend on reference to an internal “gender identity”. My previous blog posts (here, here, and here) have recounted the distressing thoughts and emotions that arise in response to seeing or touching the female secondary sexual characteristics of my body. This is the only way I can explain my experience without resorting to dichotomous gender stereotypes.

I do not know WHY my female anatomy generates such intense distress for me. I only know that it DOES. It would certainly be convenient to say that my physical dysphoria is secondary to a mismatch between my anatomy and my “gender identity”. But I fail to understand the concept of “gender identity” and I refuse to align my personal preferences and behaviors and interests with problematic and oppressive gender stereotypes for the sake of convenience. My female body (and the irrational but undeniable distress arising from my perception of it) and my human personality (my preferences, behaviors, and interests) are two separate things. “Gender is the value system that ties desirable (and sometimes undesirable?) behaviours and characteristics to reproductive function. Once we’ve decoupled those behaviours and characteristics from reproductive function – which we should – and once we’ve rejected the idea that there are just two types of personality and that one is superior to the other – which we should – what can it possibly mean to continue to call this stuff ‘gender’? What meaning does the word ‘gender’ have here, that the word ‘personality’ cannot capture?” (Reilly-Cooper 2016)

Some might argue that my claiming an absence of “gender identity” merely represents an “agender” or “non-binary” identity along a “gender spectrum”. But those terms are simply variations on the original “gender identity” concept, and therefore remain inapplicable. Rebecca Reilly-Cooper presents an excellent series of arguments explaining why the conceptualization of gender as a spectrum is not really any more progressive or inclusive than a gender binary with two opposite poles. Rather, the concept of gender as a spectrum is illogical. I encourage readers to review her essay in full but will summarize her conclusions here: “If gender identity is a spectrum, then we are all non-binary, because none of us inhabits the points represented by the ends of that spectrum… Once we recognize that the number of gender identities is potentially infinite, we are forced to concede that nobody is deep down cisgender, because nobody is assigned the correct gender… at birth. In fact, none of us was assigned a gender… at birth at all. We were placed into one of two sex classes on the basis of our potential reproductive function, determined by our external genitals. We were then raised in accordance with the socially prescribed gender norms for people of that sex. We are all educated and inculcated into one of two roles, long before we are able to express our beliefs about our innate gender identity, or to determine for ourselves the precise point at which we fall on the gender continuum. So defining transgender people as those who at birth were not assigned the correct place on the gender spectrum has the implication that every single one of us is transgender; there are no cisgender people. The logical conclusion of all this is: if gender is a spectrum, not a binary, then everyone is trans. Or alternatively, there are no trans people. Either way, this a profoundly unsatisfactory conclusion, and one that serves both to obscure the reality of female oppression, as well as to erase and invalidate the experiences of transsexual people. The way to avoid this conclusion is to realize that gender is not a spectrum. It’s not a spectrum, because it’s not an innate, internal essence or property. Gender is not a fact about persons that we must take as fixed and essential, and then build our social institutions around that fact. Gender is socially constructed all the way through, an externally imposed hierarchy, with two classes, occupying two value positions: male over female, man over woman, masculinity over femininity.” (Reilly-Cooper 2016)

(2) Typical Transgender Narratives

As a highly pathologized, stigmatized, and marginalized community, trans people are placed in a very difficult position with respect to how they describe their experience. In a clinical context, trans people must present their narrative in a way that meets the established diagnostic criteria for gender dysphoria (criteria which are based on “cross-gender identification” and evidence of behaviors and preferences stereotypically associated with the “other sex”) in order to gain access to transition therapies. In a public context, trans people must present their stories in a way that is understandable to society at large, in order to promote awareness and acceptance. Because gender stereotypes are so deeply woven into the fabric of our society, describing trans experiences in terms of strong preferences for opposite-sex stereotypes arising from an innate “gender identity” allows a publicly palatable and understandable (albeit oversimplified and problematic) narrative to emerge from within an already well-established gender framework.

“Research has suggested that adult transpeople often think that if they do not express stereotypical masculinities and femininities… they will not ﬁt the model that may steer them to the transitioning healthcare pathways… many transpeople are reluctant to relay anything to gender clinic psychiatrists that might be viewed as different from the perceived “correct” trans narrative. In previous research, I have demonstrated that transpeople tend to tailor their clinical narrativesbecause they realize that psychiatrists have the power to stop their transitioning process… transpeople retrospectively claim to have participated in stereotypically gendered play and behaviors when they have sought transitioning technologies, and have often interspersed expected gender inﬂections into their clinical narratives… These inﬂections seem inevitable because the diagnostic criteria expect cross-gendered play and behaviors to be performedprior to the granting of transitioning technologies… theclinically expected expressions of gender do not correspond well to gender role play or leisure pursuits apparent in contemporary society.” (Davy 2015)

The typical or “correct” trans narrative seems to include these main elements: strong retrospective emphasis on the early onset of gender dysphoric feelings in childhood which persisted into adolescence and adulthood, gender dysphoric feelings arising primarily from discomfort with societal gender stereotypes, assertion of a supposedly intrinsic and fixed “gender identity”, and physical dysphoria portrayed as a secondary consequence of a primary mismatch between the brain’s “gender identity” and the body’s “assigned sex”. To put it more simply, the typical trans narrative says: from a young age my personality and preferences did not align with conventional binary gender roles and gender stereotypes, therefore I must have a cross-gender or non-binary “gender identity”, therefore I must be transgender, therefore I am trapped in the wrong body, therefore my body needs to be changed to align with my “gender identity”. “Transpeople have often defined their trans gender identities through a ‘‘wrong body’’ narrative.” (Davy 2015)

Typical trans narratives not only emphasize the concept of an innate “gender identity”, they also imply that this cross-sex “gender identity” is the result of pre-natal biological factors. “Trans advocates’ essentialist claims of gender dysphoria seem to assume that society will be more accepting of transpeople if they are understood to have been ‘‘born this way”… [due to] the relative power that biogenetic discourses maintain in society and particularly in medicine.” (Davy 2015) The etiology of gender dysphoria is not clearly understood, but one of the most common theories is that exposure to altered levels of sex hormones during fetal development leads to “sex-atypical cerebral programming that diverges from the sexual differentiation of the rest of the body”. (Hoekzema 2015) However, “no evidence thus far has linked normal variability in the early hormone environment to gender dysphoria.” (Hines 2011) Additionally, people with disorders of sexual development (intersex conditions) that do cause abnormal exposure to sex hormones in utero overwhelmingly maintain a “gender identity” that aligns with the sex they were assigned at birth, rather than with the sex that their pre-natal hormone exposure more closely mimics (Hines 2011, Reiner 2011). “The majority of intersex people identified their gender as their sex assigned at birth.” (Reiner 2011) For example, female fetuses (XX chromosomes) with congenital adrenal hyperplasia have a genetic defect in adrenal enzyme pathways that leads to accumulation of androgens (such as testosterone) in the fetus’ body and causes pre-natal virilization of the female genitals. These infants are assigned female at birth. Despite high levels of pre-natal androgen exposure and masculinized genitalia, 97% of women with CAH identity as female from childhood into adulthood (Hines 2011). Male fetuses (XY chromosomes) with androgen insensitivity syndrome have normal testes and normal androgen production but lack androgen receptor molecules, which means that testosterone produced by the testes has no effect on the developing fetus. Androgen insensitivity impairs the masculinization of male genitalia in the developing fetus and the development of male secondary sexual characteristics during puberty. These XY individuals are often raised as females (particularly in cases of complete androgen insensitivity) and maintain a female “gender identity” despite having a male chromosomal configuration. (Reiner 2011) These examples provides strong evidence that “gender identity” is influenced more strongly by socialization and external gender expectations than internal biological factors like sex hormone exposure or sex chromosomes.

The typical trans narrative centers around a supposedly innate “gender identity” as an explanation for their discomfort in the body and the social role associated with their biological sex and as justification for their choices regarding transition. But as I outlined above, the concept of “gender identity” as a fixed internal property has no logical or scientific basis and relies entirely on an external frame of reference (societal gender stereotypes). “Trans advocates’ essentialist claims of gender dysphoria… and the desire to transition to a particular gender tend to mirror the simplistic dualisms from biological research, in which masculinity and femininity are regarded as natural, rather than socially constructed, characteristics.” (Davy 2015) So the emphasis on, and continued perpetuation of, the “gender identity” concept by trans advocates only serves to reinforce outdated and oppressive stereotypes.

(3) Gender Dysphoria Diagnostic Criteria

“Gender dysphoria is not always a straightforward diagnosis. This can be ascribed to the fact that international classifications are quite general and have significant short-comings, there are no objective criteria, and gender dysphoria can present in a great diversity of forms, situations, and experiences.” (Fabris 2015)

Most of the medical and psychological research regarding gender dysphoria has been based on diagnostic criteria in the American Diagnostic and Statistical Manual of Mental Disorders (DSM). I have focused on articles published since 2000, which usually refer to the diagnostic criteria for gender identity disorders in the DSM-IV and DSM-IV-TR (published in 1994 and 2000, respectively) or the criteria for gender dysphoria in the DSM-5 (published in 2013). However, some recent studies still refer to the criteria for gender identity disorders in the WHO International Statistical Classification of Diseases, the ICD-10 (published in 1993).

With respect to the DSM criteria, there is a glaring lack of validity studies or evidence supporting inter-rater reliability in the diagnostic process (Cohen-Kettenis 2009). It has been suggested that validity of the DSM diagnostic criteria can be inferred from studies evaluating sex reassignment as a treatment procedure. “Sex reassignments based on DSM diagnoses primarily resulted in satisfying results, in terms of alleviating the discomfort about one’s sex or the ‘gender dysphoria.’ Although diagnosis and response to sex reassignment are not very closely connected, and the reported findings are certainly no ‘‘proof’’ of the correctness of the diagnosis, they suggest that the elements of the DSM diagnosis are clinically useful.” (Cohen-Kettenis 2009) However, in the studies referenced by that statement, most of the subjects underwent “complete” sex reassignment. So the inferred clinical utility of DSM criteria may only apply to those who desire all aspects of sex reassignment, which is not representative of the transition goals of all trans people. “Indeed, clinicians in gender identity clinics are increasingly confronted with treatment goals other than complete sex reassignment.” (Cohen-Kettenis 2009) So the utility of the existing diagnostic criteria is, at best, limited to a subpopulation of the diverse transgender community.

One of the primary criticisms regarding the diagnostic criteria for gender identity disorder in the DSM-IV and DSM-IV-TR was the inability of the criteria to reflect the diversity of gender variance. “A problem with the current criteria is that gender identity, gender role, and gender problems are conceptualized dichotomously rather than dimensionally. For instance, the DSM-IV text states that adults with gender identity disorder are preoccupied with their wish to live as a member of the other sex, manifested as an intense desire to adopt the role of the other sex or to acquire the physical appearance of the other sex through hormonal or surgical manipulation. Within the gender identity disorder criteria, a concept such as ‘‘cross-gender identification’’ also assumes that there are only two gender identity categories, male and female.” (Cohen-Kettenis 2009) I have previously discussed my frustration that even supposedly dimensional (rather than dichotomous) scales used to measure the intensity of gender dysphoria (such as the GIDYQ-AA) leave little room for non-binary responses, and interpretation of the questions on the survey relies heavily on the reader’s alignment with stereotypical roles behaviors associated with men and women.

Prior to publishing the updated version of the DSM (DSM-5) in 2013, a workgroup was developed to revise the gender identity disorder criteria. One of the biggest revisions was a change in diagnostic terminology from gender identity disorder to gender dysphoria, to emphasize the distress associated with gender variance as being a form of psychopathology rather than gender non-conformity being considered pathological in and of itself. The goal of the workgroup was to revise the criteria in a way that would help destigmatize trans people while maintaining a diagnostic category that medical insurance companies would accept to provide financial support for transition treatments. (Davy 2015)

However, despite those revisions, the current DSM-5 criteria for gender dysphoria remain problematic. “The diagnostic framework in the DSM-5 for all transpeople continues to be underpinned by essentialist, heteronormative assumptions that situate binary sexes – male and female – with corresponding genitalia as the anchor from which gender dysphoria is judged… I would argue that the criteria proposed by the DSM-5 are derived from stereotypes applied in the gender identity clinics serving transpeople, rather than empirically developed from biological imperatives.” (Davy 2015)

Particularly disturbing is the fact that the research and clinical experience taken into account in revising the DSM-5 diagnostic criteria was based heavily on trans peoples’ clinical narratives, which (as I described above) are often tailored with added gender inflections to align more closely with the previously established criteria in order to gain access to transition options. “The DSM-5 Workgroup has disregarded the plethora of work in feminist social science which criticizes the inherency of gender roles, gender identities, and sex differences, as well as research in transgender studies that depicts non-dysphoric transpeople, desires for different embodiments, non-conventional transitioning trajectories, and sexualities. In the pre-publication reports, the Workgroup considered only the views and evidence derived from sexological research. As such, the review reflects a form of expert clinical consensus based on transpeople’s tailored narratives and questionable ideas around masculinity and femininity.” (Davy 2015)

Such a narrow-minded approach to developing diagnostic criteria based on increasingly irrelevant and biologically unjustified gender stereotypes creates a self-perpetuating cycle: trans people present their experiences in ways that align with the criteria, and the criteria are then perceived as being reinforced and validated by their alignment with trans people’s narratives. “The criteria used to diagnose gender dysphoria help psychiatrists to determine whether someone is experiencing distress about incongruence with their experienced gender through a gender normative frame… Arguably, this leads to the situation where transpeople must express incongruent behavior and demonstrate to the psychiatrist that they have most often preferred activities that are traditionally gendered and opposite to those gender norms applied to their assigned sex at birth. Within the DSM-5, these traditional gendered expressions seem to be required in spite of the lack of stark behavioral differences between the genders in Western societies today.” (Davy 2015)

And the ongoing emphasis on “gender identity” as part of the typical trans narrative and as a core diagnostic criterion further reinforces restrictive societal stereotypes. “[Most gender clinic psychiatrists] adhere togender identityas both‘‘real’’ and ﬁxed. This adherence thenfacilitates the continued use ofhighly stereotyped notions of gender to provide the framework for assessing and treating transsex individuals.” (Hird 2003)

Neither the diagnostic framework nor the professionals involved in the diagnostic process seem to recognize these problems. “Most of the clinicians seemed to take the view that individual solutions are to be sought rather than societal change – there was little suggestion that society requires any change… the clinician’s job is not to reinforce gender boundaries defined by society.” (Hird 2003)

(4) Transition as Self-Determination

I have outlined the major issues regarding the concept of “gender identity”, typical transgender narratives, and the criteria for diagnosis of gender dysphoria. I have expressed my concern that the continued dependence of “gender identity”, trans narratives, and diagnostic criteria on traditional gender norms serves to reinforce restrictive and damaging stereotypes.

My conclusion is that an inborn, immutable, intrinsic “gender identity” DOES NOT EXIST. “Gender identity” is a cognitive aspect of self-perception constructed from internalized societal gender stereotypes. The idea of an innate “gender identity” is a crutch that trans people are forced to use to legitimize their experience in the face of a society that revolves around these oppressive gender stereotypes and a psychiatric establishment that retains these troublesome stereotypes as the frame of reference for assessment and access to transition options.

A self-determination and human rights model of trans identities views the “diagnostic use of stereotypical gendered expressions associated with boys/men and girls/women as erroneous, and that they have little to do with actual contemporary gender identity formations. Accordingly, any gendered expressions, regardless of which birth-assigned sex one is given, should not act as criteria for diagnosing transpeople.” (Davy 2015)

For those who argue that inclusion of gender variance under the umbrella of psychiatry is necessary to allow access to medical and legal transition options, I would point out that some countries have already set a precedent where this is not the case. “Psychiatric involvement in healthcare pathways and legal assistance for those people who want to have a different body and/or corrected legal gender assignment should not be a requirement. They have succeeded in securing this in France, Denmark, Argentina, and Malta. In these countries, transpeople are legally recognized and are given access to healthcare services despite psychiatry being removed as the gatekeeper, because of transpeople demanding healthcare and legal recognition through a self-determination model of gender variance.” (Davy 2015)

“The solution is not to reify gender by insisting on ever more gender categories that define the complexity of human personality in rigid and essentialist ways. The solution is to abolish gender altogether. We do not need gender. We would be better off without it. Gender as a hierarchy with two positions operates to naturalize and perpetuate the subordination of female people to male people, and constrains the development of individuals of both sexes… You do not need to have a deep, internal, essential experience of gender to be free to dress how you like, behave how you like, work how you like, love who you like… The solution to an oppressive system that puts people into pink and blue boxes is not to create more and more boxes that are any colour but blue or pink. The solution is to tear down the boxes altogether.” (Reilly-Cooper 2016)

“Gender identity” needs to disappear. “Transition” should be removed from a gender context and the term “transgender” should be rendered obsolete. Instead, the medical, legal, and social aspects involved in “transition” should be viewed – simply and respectfully – as a human right to self-determination. “Assuming an inner-self who desires such a transformation, gender transitions are thus situated in a non-essentialized experiential framework, anchored in self-determination.” (Davy 2015) People – ALL people, not just trans people – should be free to modify their physical attributes, adopt social roles, and pursue interests that align with their personal preferences and desires. We are all of us “transitioning” all the time, as we learn and grow and adapt to an ever-changing world. “Transition” (in a transgender context) is just one of many ways that people strive for self-expression that makes them feel comfortable. “Transition” (in a human context) is an ongoing process for each of us to create an authentic self in this vast ocean of human diversity.

“If there’s no meaning in it, that saves a world of trouble, you know, as we needn’t try to find any.”– The King (Alice’s Adventures in Wonderland, 1865)